The Home Health PT's Guide to Billing for Outpatient Services

Did you know that the singular form of the word “confetti” is “confetto”? Or that sharks have literally attacked the Internet? Or that we can thank Shakespeare for inventing the word “manager?” (Yeah, that one surprised me, too!) There’s a lot of collective human knowledge that each of us as individuals will never get a chance to learn about—and I mean a lot. Simply reading the entire Internet would take a couple dozen million years. No one can know everything (except for a few Jeopardy! contestants), and it’s easy to accept that—until you realize that you might be missing out on some super-specific lesser-known facts that could make a huge difference in your professional life. 

For instance: Did you know that home health agencies (HHAs) can bill Medicare for outpatient services? Crazy, right? Now, I may not have encyclopedic knowledge (and you won’t see me on Jeopardy! any time soon), but at the very least, I can pass on the details of this niche billing tactic. Check out these home health physical therapy guidelines for outpatient HHA services. 

Following the Rules

Now, before you rush out and snap up some CMS-1500 forms, there are a few things you need to know about this special type of outpatient billing. The first is that HHAs may only bill Medicare for outpatient services if the patients are “not homebound or otherwise are not receiving services under a home health plan of care (POC).” In other words, Medicare will not reimburse a patient’s outpatient Part B claims at the same time it is actively reimbursing that patient’s inpatient Part A claims.  

Second, when an HHA submits an outpatient claim, the claim will be reimbursed per the Medicare Physician Fee Schedule (i.e., at Part B rates)—not the Home Health Prospective Payment System (i.e., at Part A rates).

Additionally, these claims should be billed with the HHA’s current Medicare and NPI numbers, which means the HHA won’t have to apply for any additional credentialing in order to successfully bill outpatient claims (hooray!).

Filling out a Claim Form

If that’s not cheer-worthy enough, get this: submitting an outpatient HHA claim isn’t all that difficult. You simply fill out a fresh UB-04 form. When the UB-04 asks about the claim type, jot down 34X (where X denotes frequency), and fill out the rest of the form as directed. 

Covering Your Bases

One important thing to keep in mind is that Part B has different coverage requirements than Part A. So, if you bill something that Medicare doesn’t cover, you won’t receive reimbursement, and you can’t collect from the patient—unless you have an Advance Beneficiary Notice of Noncoverage (ABN) on file, that is. The Medicare Claims Processing Manual explicitly states that HHAs that provide outpatient care (or supply devices) are responsible for collecting ABNs from patients when they intend to bill outpatient. Just remember that ABNs must be administered on a case-by-case basis—and never via blanket ban. 

Recognizing the Possibilities

At this point, you may be wondering why billing a home visit as an outpatient visit is beneficial for an inpatient therapist—especially with Part B reimbursement rates constantly on the chopping block. And honestly, that’s a valid question. After all, therapists have had to grow increasingly business savvy to preserve their financial health amid declining reimbursements. 

Financial Gains

The good news is that providing outpatient services could actually help your HHA’s finances in the long run. As this article from Symbria points out, if a homebound patient has improved to the point that he or she no longer needs inpatient care, you don’t have to discharge the patient and wave goodbye to him or her forever. Instead, you can retain him or her as a revenue source by continuing to provide care—with a goal of improving or simply maintaining the patient’s status. This is pretty great considering that attracting new patients is way more expensive than retaining current ones—and merely generating referrals can be tough at times.  

Improved Patient Care

Quite possibly the best reason for an HHA to bill for outpatient care is that it can be beneficial to patients. After all, care continuity improves clinical outcomes—especially for patients with chronic illnesses. If you continue to provide outpatient services to a patient after he or she is no longer homebound, the patient is more likely to achieve his or her mobility goals. Besides, who better to administer the outpatient therapy than the therapist who is already familiar with the patient’s unique case?

At the end of the day, you probably (definitely) won’t be able to remember every one of life’s little fun facts (like that scissors were invented in Egypt around 1,500 B.C.). But you can at least be an expert in what you do best: rehab therapy. Who knows; maybe there will be a PT category on Jeopardy! some day.